Provider Demographics
NPI:1447474689
Name:WELLNESS ONE MARIETTA
Entity type:Organization
Organization Name:WELLNESS ONE MARIETTA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MIDDLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-850-0857
Mailing Address - Street 1:PO BOX 672542
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30006-2542
Mailing Address - Country:US
Mailing Address - Phone:770-795-0506
Mailing Address - Fax:770-795-0392
Practice Address - Street 1:2727 CANTON ROAD
Practice Address - Street 2:SUITE # 520
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066
Practice Address - Country:US
Practice Address - Phone:770-795-0506
Practice Address - Fax:770-795-0392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA6328111N00000X
GAGA5936111N00000X
GA024767207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGGGMedicare UPIN
GA35ZCFGWMedicare ID - Type Unspecified